Healthcare Provider Details

I. General information

NPI: 1093820995
Provider Name (Legal Business Name): CHARLES D. LLANO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 W HIGHLAND DR
LAKELAND FL
33813-1543
US

IV. Provider business mailing address

320 W HIGHLAND DR
LAKELAND FL
33813-1543
US

V. Phone/Fax

Practice location:
  • Phone: 863-644-2428
  • Fax: 863-644-6235
Mailing address:
  • Phone: 863-644-2428
  • Fax: 863-644-6235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN 6425
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: